Hepatitis C Screening Beyond CDC Guidelines
Hepatitis C Screening Beyond CDC Guidelines
The Hepatitis Outreach Network (HONE) is a collaboration of the Mount Sinai School of Medicine (MSSM), the New York City Department of Health and Mental Hygiene (NYC DOHMH) and community-based organizations (CBOs), was designed in 2009 by members of the MSSM Division of Liver Diseases to link foreign-born persons with HBV and/or HCV infection to care. The HONE collaboration and overall results have been previously described elsewhere. The HONE programme in partnership with CBOs including Harbor Light Community Health, Egyptian American Medical Society, the Arab American Association and Lutheran Family Health Centers conducted four community-based screening events targeting Egyptian-born persons in New York City and New Jersey. Printed public service advertisements (PSA) in both English and Arabic were posted throughout the community with the time, date and location of the events to invite participants for free HCV counselling and testing. All persons over the age of 18 years old and with a working telephone number were invited to participate.
Screening was conducted at places of worship (mosques and churches), public spaces (train stations and parks) and community centres. HONE identified and trained bilingual Arabic-English-speaking patient navigators (PNs) for linkage to care. Bilingual Arabic-English-speaking volunteers were recruited and trained to obtaining written informed consent for this study. This study protocol was approved by the MSSM Institutional Review Board. After providing consent, participants completed a self-administered, printed survey in English or in Arabic. The survey included questions on demographics, socioeconomic status, medical history, family history and traditional risk factors for HCV infection. After participants completed the survey, trained phlebotomists drew a single tube of their blood (<10 ml). The blood was tested at the MSSM Clinical laboratories for HCV antibody (HCV Ab) (ELISA and RIBA). Persons with HCV Ab were defined as having HCV infection. Laboratory studies were completed within 3 days after each event.
Patient navigators made at least six telephone calls at three different times of the day to reach participants, provide blood test results and provide follow-up recommendations. Persons not reached within 6 months were considered lost to follow-up. Participants with HCV infection were encouraged by PNs to receive a full medical evaluation from a healthcare provider and provided telephone-based navigation by PNs. A bilingual PN was designated to make all phone calls and free full medical evaluations at MSSM were offered and recommended. PNs scheduled visits, provided reminders via telephone and postcards. Participants who came to the MSSM Liver Medicine Practice were reimbursed for transportation. HCV-positive persons who opted to not attend a follow-up visit at MSSM were offered follow-up visits at the Lutheran Family Health Center with an Arabic-speaking provider.
All patients who attended a follow-up visit at MSSM were seen by a hepatologist (PP) who took a history and performed a physical examination. Each of these patients had an ultrasound, and blood was obtained for HCV viral load and genotype testing (Roche Molecular Systems, Inc., Branchburg, NJ, USA performed at ARUP Laboratories). Persons with HCV infection were recommended treatment based on the AASLD Treatment Guidelines (i.e. patients with detectable virus were recommended for further evaluation and treatment). HCV Ab-positive persons with undetectable HCV viral load, which suggests spontaneous viral clearance, were counselled that further treatment was not required.
Mount Sinai School of Medicine Liver Medicine Practice did not offer care to participants after the full medical evaluation. Participants who received recommendations to start treatment immediately, were navigated to seek their primary care providers, if they had one, or to federally qualified health centers (FQHCs), if they did not. Participants, particularly those without insurance were directed to FQHCs and given information on how to try to obtain insurance and follow-up care. For these individuals, the MSSM-based PN called a previously identified point person at a local FQHC in the borough of residence, scheduled an appointment and later called participants to remind them of their FQHC appointment. Participants were contacted 6 months after their full medical evaluation to determine which recommendations were followed.
This study recorded birth date and the year an individual moved to the USA from Egypt. This information was used to directly calculate the number of years the respective individual was resident in Egypt before moving to the USA. The known high prevalence of HCV in Egypt suggests that duration of residency in Egypt maybe associated with a higher prevalence of HCV in those who had longer residency.
Data were analysed using spss (v 20.0, Armonk, NY, USA). The primary outcome was testing positive for HCV. Univariate logistic regression was used to identify variables most likely to have an effect on attending a follow-up visit. Categorical variables were compared using the chi-squared test (χ, P ≤ .05), while continuous variables were compared by logistic regression. Odds ratios were used as a measure of association and 95% CIs were calculated for all estimates.
Methods
Study Population
The Hepatitis Outreach Network (HONE) is a collaboration of the Mount Sinai School of Medicine (MSSM), the New York City Department of Health and Mental Hygiene (NYC DOHMH) and community-based organizations (CBOs), was designed in 2009 by members of the MSSM Division of Liver Diseases to link foreign-born persons with HBV and/or HCV infection to care. The HONE collaboration and overall results have been previously described elsewhere. The HONE programme in partnership with CBOs including Harbor Light Community Health, Egyptian American Medical Society, the Arab American Association and Lutheran Family Health Centers conducted four community-based screening events targeting Egyptian-born persons in New York City and New Jersey. Printed public service advertisements (PSA) in both English and Arabic were posted throughout the community with the time, date and location of the events to invite participants for free HCV counselling and testing. All persons over the age of 18 years old and with a working telephone number were invited to participate.
Screening
Screening was conducted at places of worship (mosques and churches), public spaces (train stations and parks) and community centres. HONE identified and trained bilingual Arabic-English-speaking patient navigators (PNs) for linkage to care. Bilingual Arabic-English-speaking volunteers were recruited and trained to obtaining written informed consent for this study. This study protocol was approved by the MSSM Institutional Review Board. After providing consent, participants completed a self-administered, printed survey in English or in Arabic. The survey included questions on demographics, socioeconomic status, medical history, family history and traditional risk factors for HCV infection. After participants completed the survey, trained phlebotomists drew a single tube of their blood (<10 ml). The blood was tested at the MSSM Clinical laboratories for HCV antibody (HCV Ab) (ELISA and RIBA). Persons with HCV Ab were defined as having HCV infection. Laboratory studies were completed within 3 days after each event.
Link to Care
Patient navigators made at least six telephone calls at three different times of the day to reach participants, provide blood test results and provide follow-up recommendations. Persons not reached within 6 months were considered lost to follow-up. Participants with HCV infection were encouraged by PNs to receive a full medical evaluation from a healthcare provider and provided telephone-based navigation by PNs. A bilingual PN was designated to make all phone calls and free full medical evaluations at MSSM were offered and recommended. PNs scheduled visits, provided reminders via telephone and postcards. Participants who came to the MSSM Liver Medicine Practice were reimbursed for transportation. HCV-positive persons who opted to not attend a follow-up visit at MSSM were offered follow-up visits at the Lutheran Family Health Center with an Arabic-speaking provider.
All patients who attended a follow-up visit at MSSM were seen by a hepatologist (PP) who took a history and performed a physical examination. Each of these patients had an ultrasound, and blood was obtained for HCV viral load and genotype testing (Roche Molecular Systems, Inc., Branchburg, NJ, USA performed at ARUP Laboratories). Persons with HCV infection were recommended treatment based on the AASLD Treatment Guidelines (i.e. patients with detectable virus were recommended for further evaluation and treatment). HCV Ab-positive persons with undetectable HCV viral load, which suggests spontaneous viral clearance, were counselled that further treatment was not required.
Mount Sinai School of Medicine Liver Medicine Practice did not offer care to participants after the full medical evaluation. Participants who received recommendations to start treatment immediately, were navigated to seek their primary care providers, if they had one, or to federally qualified health centers (FQHCs), if they did not. Participants, particularly those without insurance were directed to FQHCs and given information on how to try to obtain insurance and follow-up care. For these individuals, the MSSM-based PN called a previously identified point person at a local FQHC in the borough of residence, scheduled an appointment and later called participants to remind them of their FQHC appointment. Participants were contacted 6 months after their full medical evaluation to determine which recommendations were followed.
This study recorded birth date and the year an individual moved to the USA from Egypt. This information was used to directly calculate the number of years the respective individual was resident in Egypt before moving to the USA. The known high prevalence of HCV in Egypt suggests that duration of residency in Egypt maybe associated with a higher prevalence of HCV in those who had longer residency.
Statistical Analysis
Data were analysed using spss (v 20.0, Armonk, NY, USA). The primary outcome was testing positive for HCV. Univariate logistic regression was used to identify variables most likely to have an effect on attending a follow-up visit. Categorical variables were compared using the chi-squared test (χ, P ≤ .05), while continuous variables were compared by logistic regression. Odds ratios were used as a measure of association and 95% CIs were calculated for all estimates.
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